Current Management of Hyperkalemia in Patients on Dialysis Shweta Bansal 1 and Pablo E. Pergola 1,2 1 Division of Nephrology, UT Health at San Antonio, San Antonio, Texas, USA; and 2 Renal Associates, P.A., San Antonio, Texas, USA Patients with end-stage renal disease (ESRD) on maintenance dialysis have a high risk of developing hyperkalemia, generally defined as serum potassium (K þ ) concentrations of >5.0 mmol/l, particularly those undergoing maintenance hemodialysis. Currently, the key approaches to the management of hyperkalemia in patients with ESRD are dialysis, dietary K þ restriction, and avoidance of medications that increase hyperkalemia risk. In this review, we highlight the issues and challenges associated with effective management of hyperkalemia in patients undergoing maintenance dialysis using an illustrative case presentation. In addition, we examine the potential nondialysis options for the management of these patients, including use of the newer K þ binder agents patiromer and sodium zirconium cyclosilicate, which may reduce the need for the highly restrictive dialysis diet, with its own implication on nutritional status in patients with ESRD, as well as reducing the risk of potentially life-threatening hyperkalemia. Kidney Int Rep (2020) 5, 779–789; https://doi.org/10.1016/j.ekir.2020.02.1028 KEY WORDS: dialysis; end-stage renal disease; hyperkalemia; patiromer; serum potassium; sodium zirconium cyclosilicate ª 2020 International Society of Nephrology. Published by Elsevier Inc. This is an open access article under the CC BY- NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). T he overall prevalence of ESRD in the United States is increasing, with >725,000 cases in 2016. 1 He- modialysis (HD) was used as renal replacement therapy in 63% of these prevalent patients, and peritoneal dialysis (PD) in 7%; the remaining 30% of patients underwent kidney transplantation. 1 Most patients (98%) undergoing HD were on in-center HD, with only 2% on home HD. 1 Patients undergoing maintenance HD have a high risk of hyperkalemia, generally defined as serum po- tassium (K þ ) concentrations of >5.0 mmol/l, even when receiving adequate treatment with 3-times-weekly HD (Figure 1). 2,3 Hyperkalemia is a potentially life- threatening disorder that can cause arrhythmias and sudden cardiac arrest. 3,4 In a US cohort study of pa- tients undergoing HD between 2007 and 2010, the rate of hyperkalemia (K þ $5.5 mmol/l) was 16.3 to 16.8 per 100 patient-months. 3 More recently, the PORTEND (POtassium and Cardiac Rhythm Trends in MaintE- Nance HemoDialysis) observational study of US pa- tients on maintenance HD showed that the incidence of predialysis hyperkalemia (K þ >5.0 mmol/l) after the long interdialytic interval was 37% and 21% among patients on dialysate K þ concentrations of #2 and $3 mmol/l, respectively (Singh B, Block G, Lerma EV, et al. Hyperkalemia and serum potassium variability in patients on hemodialysis [abstract]. Am J Kidney Dis. 2017;69:A3. Late-breaking abstract 6). Patients under- going PD have a lower risk of developing hyperkalemia than those on HD because of the continuous nature of PD treatment 5 and the fact that many patients on PD retain residual kidney function for longer than those on HD and receive high-dose diuretics, which increases the urinary excretion of K þ6 ; however, the risk of hypokalemia is increased in these patients, with a prevalence of between 10% and 36%. 7–9 In a meta- analysis of observational studies, the risk of cardio- vascular mortality in patients on dialysis was increased by 1.4-fold with hyperkalemia and by 1.1-fold with hypokalemia. 4 Taken together, these studies emphasize the importance of maintaining serum K þ concentrations within the normal range in patients on dialysis. Furthermore, hyperkalemia is associated with an increased health care burden in patients with chronic kidney disease. 10 The goals of HD in patients with ESRD include the removal of excess K þ that accumulates between dialysis sessions to avoid potentially serious predialysis hyperkalemia, while at the same time preventing Correspondence: Shweta Bansal, Division of Nephrology, Department of Medicine, UT Health at San Antonio, 7703 Floyd Curl Drive, MSC 7882, San Antonio, Texas 78229, USA. E-mail: [email protected] Received 4 December 2019; revised 10 February 2020; accepted 14 February 2020; published online 26 February 2020 Kidney International Reports (2020) 5, 779–789 779 REVIEW
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